Abstract
Purpose
Endoscopic retrograde cholangiopancreatography (ERCP) is a useful tool in the management of pancreaticobiliary disorders. However, experience in pediatric ERCP is limited and criteria for competency remain undefined. In this retrospective single-center audit, we reviewed the indications, success rates, and adverse events associated with pediatric ERCP at the largest pediatric hospital in Singapore.
Methods
Medical records of patients aged 0-18 years who underwent ERCP between 2014 and 2024 were reviewed. All procedures were performed by endoscopists routinely treating adults. Data on demographics, medical history, indications and findings of ERCP, operative procedures, and adverse events were collected.
Results
Thirty-eight ERCP procedures were performed on 20 patients. The youngest patient was 19 months of age and weighed 8 kg. The median patient age was 12 years (2–17) years. Biliary obstruction was the most common indication (18/38 [47.8%]). The cannulation and technical success rates were both 94.7% (36/38). More than half of the patients underwent complex endoscopic procedures of at least American Society for Gastrointestinal Endoscopy level 3 complexity. Complications occurred in 4 of 38 (10.5%) procedures, including post-ERCP cholangitis, pancreatic duct perforation, post-ERCP pancreatitis, and post-sphincterotomy bleeding.
Conclusion
Pediatric ERCP performed by experienced endoscopists routinely treating adults was successful and safe even in a low-volume setting with complex interventions.
Keywords: Cholangiopancreatography, endoscopic retrograde; Endoscopy, gastrointestinal; Hospitals, pediatric; Clinical audit
INTRODUCTION
Endoscopic retrograde cholangiopancreatography (ERCP) is a well-established diagnostic and therapeutic tool in adult patients for the management of hepatobiliary and pancreatic disease [1]. However, the experience in children remains relatively limited, owing to the lower incidence of pancreaticobiliary conditions in this age group and limited availability of trained endoscopists to perform ERCP in children [2]. A common perception is that ERCP is more technically difficult in pediatric patients owing to their smaller anatomical dimensions and are associated with higher risk of adverse events [1]. However, improved designs of endoscopes and instruments have facilitated the safe use of ERCP even in infants, and it has been used in the diagnosis of biliary atresia [3].
Recent data from high-volume regional hepatobiliary centers have demonstrated high technical success rates and favorable safety and risk profile in ERCP performed on children and adolescents, supporting its role in managing pediatric pancreaticobiliary diseases [4,5]. A recently published multi-site study on pediatric ERCP experience has reported a procedure success rate of 95.5% [6]. In the United States, the annual numbers of pediatric ERCPs performed have been rising, and the procedures are generally performed for therapeutic indications [7]. Recently, a meta-analysis of 52 studies on ERCP in children has indicated that the most common indication for ERCP was in biliary conditions (48%) and overall complication rate was 7%, with the highest being post ERCP pancreatitis [8].
Nonetheless, it is still widely recognized that ERCP demands a higher level of technical competence than standard gastrointestinal endoscopy, and the success and complication risk may be operator dependent [9]. Pediatric ERCP competency is challenged by relatively low pediatric caseload compared with that of adults and inherent difficulties in performing the procedure in small children. Existing guidelines suggest minimum ERCP volumes for attaining competence; however, the true number remains debatable, and pediatric-specific guidelines are lacking [10]. Moreover, most pediatric ERCPs are performed by endoscopists trained in adult-gastroenterology, whose knowledge with pediatric anatomy and disease may vary.
We report a single-institution audit of ERCP indications, technical success, and adverse events in children treated at the largest tertiary pediatric center in Singapore, which manages most of the nation’s pediatric caseload.
MATERIALS AND METHODS
A retrospective audit was conducted on all pediatric patients aged 0–18 years at the KK Women’s and Children’s Hospital (KKH) in Singapore who underwent ERCP during the study period between 2014 and 2024. The patients were identified from the department’s endoscopy database. ERCP was performed by two expert gastroenterologists (C.K. and D.T.) from Singapore General Hospital (SGH), the largest tertiary-level acute-care adult hospital in Singapore. Prior to 2017, the procedures were performed on-site at KKH, whereas since 2017, the patients have been transferred to SGH for the procedure and returned to KKH by ambulance over a 9-km road journey for inpatient post-procedure monitoring for 24–48 hours. Duodenoscopes (Olympus TJF160V or Olympus TJF-Q180V, both 11.3 mm in diameter with a 4.2-mm channel) were used. All procedures were performed under general anesthesia (GA) or sedation with monitored anesthesia care, with the support of trained pediatric anesthetists. Preprocedure intravenous hydration and the use of prophylactic nonsteroidal anti-inflammatory drugs were part of the standard management.
Cannulation success was defined as successful deep cannulation of the desired duct based on preprocedural indications. Technical success was defined as successful cannulation and achievement of the desired diagnostic or therapeutic indication [11]. Therapeutic interventions included biliary or pancreatic sphincterotomy, biliary or pancreatic duct dilatation, stone removal, and stent placement. An adverse event was defined as an event that prevented completion of the planned procedure, prolonged the hospital stay, or required another procedure within 14 days of the procedure. Complications were classified in accordance with the guidelines published in the 2010 lexicon of definitions by the American Society of Gastrointestinal Endoscopy (ASGE) [12]. Post-ERCP bleeding was defined as bleeding (hematemesis or melena) with a hemoglobin drop of >2 g/dL. Perforation was defined as the presence of air or luminal contents outside the gastrointestinal tract. Post-ERCP pancreatitis was defined as new or worsened abdominal pain associated with an elevation in pancreatic enzyme levels by more than three times the upper limit of the normal range. Post-ERCP cholangitis was defined as new onset fever of >38°C for more than 24 hours with cholestasis.
Data collected from medical records included demographic information, medical history, laboratory and imaging findings, indications, ERCP operative procedures, and procedure-related adverse events. ERCP complexity scores were graded from levels 1 to 4 in increasing difficulty according to the ASGE work group classification [13]. Descriptive statistics were calculated for all variables, with mean (standard deviation) and median (range) reported for continuous variables and percentages for categorical variables. Group differences by ERCP-related complication status were assessed using chi-square for categorical variables and independent t-test for continuous variables. Statistical analyses were performed using Microsoft Excel (Microsoft Co.). The study was reviewed by the SingHealth Institutional Review Board (IRB), which decided that the purpose and design of this clinical audit met the criteria for waiving IRB approval.
Ethical statement
The hospital’s Institutional review board was consulted, and approval was not required to conduct this clinical audit.
RESULTS
A total of 38 ERCPs were performed in 20 patients over the 11-year study period (Fig. 1). Ten patients underwent repeated procedures (Table 1). Table 1 summarizes baseline demographic and biochemistry profiles, including liver function tests, by underlying diagnosis. The median age at the time of ERCP was 12 years (range: 19 months–17 years), and the median weight was 44 (range: 8–68) kg (Table 2).
Fig. 1. Number of ERCP procedures per year (2014–2024).
ERCP: endoscopic retrograde cholangiopancreatography.
Table 1. Demographics and baseline characteristics of patients who underwent ERCP, by diagnosis.
| Variable | Total patients (N=20) | Choledocholithiasis | Acute or chronic pancreatitis | Choledochal cyst | Bile leak post traumatic bile duct injury | |
|---|---|---|---|---|---|---|
| Total patients | 20 | 10 (50.0) | 5 (25.0) | 4 (20.0) | 1 (5.0) | |
| Total number of ERCPs | 38 | 15 | 15 | 5 | 3 | |
| More than one ERCP performed | 10 | 3 | 5 | 1 | 1 | |
| Median age at first ERCP | 12 (2–17) | 11.5 (2–17) | 11.5 (10–17) | 8.5 (4–16) | 7 | |
| Baseline laboratory values | ||||||
| Total bilirubin (µmoL/L) | 21.5 (4–1,083) | 91 (6–1,083) | 8.5 (5–10) | 43.5 (22–58) | 12 | |
| AST (U/L) | 62.5 (13–470) | 84 (29–470) | 22.5 (15–28) | 127 (84–165) | 86 | |
| ALT (U/L) | 112.5 (10–433) | 192 (39–433) | 23 (16–41) | 209.5 (127–356) | 98 | |
| GGT (U/L) | 136.5 (10–1,255) | 178 (123–1,255) | 35 (13–67) | 359 (228–803) | 244 | |
| Amylase (U/L) | 93 (14–1,445) | 56.5 (14–1,445) | 174.5 (83–286) | 181.5 (97–252) | 34 | |
| Lipase (U/L) | 124 (13–>600) | 13 (13–13) | 600 (253–600) | Not conducted | Not conducted | |
| Hemoglobin (g/dL) | 12.8 (8.6–16.4) | 11.8 (8.6–15.5) | 13 (12.9–14.4) | 12.3 (11.7–16.4) | 14.8 | |
| Total white cell count (×109/L) | 7.63 (5.1–19.4) | 9.25 (6.87–19.4) | 7.1 (6.85–11.1) | 7.58 (6.45–12.9) | 14.02 | |
| Platelet (×109/L) | 305.5 (187–475) | 243 (187–440) | 309 (249–313) | 309.5 (265–340) | 360 | |
| INR | 1.11 (1.02–1.53) | 1.12 (1.02–1.53) | 1.3 (1.3–1.3) | 1.08 (1.03–1.14) | 1.07 | |
| APTT (seconds) | 40.8 (26.5–48.9) | 41.2 (29.6–48.9) | 35.4 (26.5–47.9) | 43.3 (38.7–45.8) | 47.3 | |
| Prothrombin time (seconds) | 13.8 (10–17.6) | 14.2 (13–17.6) | 12.5 (10.1–15.5) | 13.3 (13.2–14.2) | 13.5 | |
| Underwent prior MRCP | 16 | 7 | 5 | 3 | 1 | |
Values are presented as number only or median (range).
ERCP: endoscopic retrograde cholangiopancreatography, AST: aspartate aminotransferase, ALT: alanine aminotransferase, GGT: gamma-glutamyl transferase, INR: international normalized ratio, APTT: activated partial thromboplastin time, MRCP: magnetic resonance cholangiopancreatography.
Table 2. Details of ERCP performed (n=38).
| Variable | All ERCPs (n=38) | ERCPs without complications (n=34) | ERCPs with complications (n=4) | p-value | ||
|---|---|---|---|---|---|---|
| Age range of patients at the time of procedure (yr) | ||||||
| 2–5 | 4 (10.5) | 4 (11.8) | 0 (0.0) | 0.913 | ||
| 6–10 | 8 (21.1) | 8 (23.5) | 0 (0.0) | 0.755 | ||
| 10–18 | 26 (68.4) | 22 (64.7) | 4 (100.0) | 0.559 | ||
| Median age of patients at the time of procedure (yr) | 12 (2–17) | 11 (2–17) | 16 (13–17) | 0.06 | ||
| Median weight at the time of procedure (kg) | 44 (8–68) | 42 (8–68) | 53 (38–56) | 0.292 | ||
| Indications | ||||||
| Biliary | ||||||
| Biliary obstruction | 18 (47.3) | 15 (44.1) | 3 (75.0) | 0.713 | ||
| Traumatic bile duct leak | 2 (5.3) | 2 (58.8) | 0 (0.0) | 0.969 | ||
| Pancreatic | ||||||
| Acute recurrent pancreatitis | 13 (34.2) | 12 (35.3) | 1 (25.0) | 0.982 | ||
| Related to prior procedure | ||||||
| Final removal of biliary or pancreatic stent | 5 (13.1) | 5 (14.7) | 0 (0.0) | 0.878 | ||
| Complexity of ERCP procedure according to the AGSE score | ||||||
| Level 1 (deep cannulation of duct of interest, biliary stent removal/exchange) | 9 (23.7) | 9 (26.5) | 0 (0.0) | 0.708 | ||
| Level 2 (biliary stone extraction <10 mm, treatment of extrahepatic strictures, and placement of prophylactic pancreatic stents) | 9 (23.7) | 7 (20.6) | 2 (50.0) | 0.634 | ||
| Level 3 (biliary stone extraction >10 mm, treatment of pancreatic strictures and stones <5 mm, and treatment of acute or recurrent pancreatitis) | 18 (47.3) | 16 (47.1) | 2 (50.0) | 0.999 | ||
| Level 4 (removal of internally migrated pancreatic stents, impacted or >5 mm pancreatic stones, and pseudocyst drainage) | 2 (5.3) | 2 (5.9) | 0 (0.0) | 0.969 | ||
| Received prophylactic rectal diclofenac (n=32) | 23 (71.9) | 20 (58.8) | 3 (75.0) | 0.942 | ||
| Mean duration of procedure (min) | 47.3±27.5 | 45.3±27.0 | 77.5±17.7 | 0.110 | ||
| Cannulation success of procedure | 36 (94.7)* | 33 (97.1) | 3 (75.0) | 0.322 | ||
| Technical success | 36 (94.7)* | 33 (97.1) | 3 (75.0) | 0.322 | ||
| Median length of stay post procedure (d) | 3 (0–26) | 3 (0–10) | 4.5 (1–26) | 0.004 | ||
| ERCP-related complications | ||||||
| Post-ERCP cholangitis | 1 | - | See first column | NA | ||
| Post-sphincterotomy bleed | 1† | |||||
| Post-ERCP pancreatitis | 2† | |||||
| Perforation of pancreatic duct side branch | 1 | |||||
Values are presented as number (%), median (range), or mean±standard deviation. ERCP: endoscopic retrograde cholangiopancreatography, NA: not available.
*Failed to cannulate pancreatic duct and bypass pancreatic stricture on both ERCP attempts in the same patient (17-year old male patient).
†Complications of post-sphincterotomy bleed and post-ERCP pancreatitis occurred in the same patient in one ERCP procedure.
Twenty (52.6%) of the 38 ERCPs were performed at the time of acute presentation on an urgent or semi-urgent basis, whereas the remaining 18 procedures were planned and performed electively, either after an interval following a symptomatic episode, evaluation of incidental stone findings on imaging, persistent cholestasis, or removal or replacement of stent.
The most common indication for pediatric ERCP in our cohort was biliary obstruction (47.3%), followed by pancreatic duct obstruction that led to recurrent pancreatitis (34.2%) (Table 2). Of the 10 patients diagnosed with choledocholithiasis, 8 had underlying predisposing factors such as chronic hemolytic disorders (n=5), familial dyslipidemia (n=2), and inflammatory bowel disease (n=1), while 2 patients had idiopathic gallstone formation. A spectrum of endoscopic interventions of varying complexity were performed (Table 2). Over half (52.6%) of the procedures were ASGE level ≥3, including the removal of large biliary or pancreatic stones and treatment of pancreatic strictures causing recurrent acute pancreatitis.
Cannulation and technical success rates were both 94.7% (36/38). Cannulation failed in only 1 patient who underwent 2 ERCPs. This 17-year old male presented with recurrent pancreatitis due to a tight pancreatic duct stricture that could not be cannulated on either ERCP attempt.
Complications occurred in 4 out of 38 (10.5%) procedures, and the details of their ERCP procedure and the management of complications are described in Table 3. One patient had post-sphincteromy bleeding, leading to an extensive duodenal hematoma causing intestinal obstruction and post-ERCP pancreatitis. The patient required emergency esophagogastroduodenoscopy for bleeding hemostasis (via adrenaline injection), intensive care treatment, and short-term parenteral nutrition. One patient had a pancreatic duct side branch perforation, which was managed conservatively. Both patients had underlying choledochal cyst. One patient developed post-ERCP pancreatitis after difficult cannulation past a pancreatic duct stricture and eventually underwent Puestow’s operation. The last patient (with normal anatomy) had post-ERCP cholangitis requiring a repeat ERCP procedure for biliary stent placement. No mortality was observed in any patient. No anesthesia-related complications were observed. No statistically significant variables were identified in the comparison between the patients with ERCP-related complications and those who underwent uncomplicated procedures (Table 2). Only the length of stay was significant (p=0.004); however, a longer duration of stay was expected in the group of patients who experienced adverse events.
Table 3. Cases of ERCP-related complications.
| Age/sex | MRCP performed | Weight (kg) | Diagnosis | Type of complication | ERCP procedure | Treatment |
|---|---|---|---|---|---|---|
| 16-yr old male patient | No | 53 | Distal common bile duct stone | Post-ERCP cholangitis | Biliary sphincterotomy was performed with pigment stone fragments removed. Pancreatogram showed normal main pancreatic duct and cholangiogram showed non-dilated CBD with smooth distal tapering. A small filling defect was detected at the distal CBD. Multiple balloon trawling was performed. Occlusion cholangiogram showed no residual filing defects. | Admitted next day and underwent a repeat ERCP for biliary stent placement and discharged with oral antibiotics. |
| 16-yr old male patient | Yes | 53 | Type IV choledochal cyst with common bile duct stone | i) Upper gastrointestinal bleed from bleeding from ERCP sphincterotomy site | ERCP showed anomalous Pancreaticobiliary junction with overall features suggestive of type IV choledochal cyst. Biliary sphincterotomy and sphincteroplasty were performed. | Underwent emergency esophagoduodenoscopy next day and hemostasis achieved with adrenaline and sureclip application. |
| ii) Post-ERCP pancreatitis complicated by septic shock | Initial sweep with basket and balloon of distal CBD removed small whitish proteinaceous stones indicating pancreatic type stones. | Treated with intravenous antibiotics and fluid bolus for septic shock. | ||||
| iii) Intestinal obstruction from post-ERCP duodenal hematoma | Subsequently, larger distal CBD stones, which were cholesterol stones, were removed. | Required short term parenteral nutrition in view of intramural hematoma in duodenum D2 to duodeno-jejunal flexure. | ||||
| A decision was made not to perform cholangioscopy, and a large CHD stone was removed, as the CBD was kinked in a fixed position, which would require surgery for long-term management. | ||||||
| One 10 Fr×12-cm biliary stent was placed with good outflow of contrast with proximal end in the CHD. | ||||||
| 13-yr old female patient | No | 38 | Todani type 1D choledochal cyst, with anomalous pancreaticobiliary junction and choledocholithiasis. | Perforation of the pancreatic duct side branch | Biliary sphincterotomy was performed over a guidewire placed deep into the common bile duct. Attempted trapezoid lithotripter basket over the guidewire was unsuccessful with no progression beyond the distal duct. With partial opening of the basket and contrast injection, extravasation was observed. | Treated with pancreatic stent placement |
| 17-yr old male patient | Yes | 56 | Recurrent pancreatitis with pancreatic duct stricture | Post-ERCP pancreatitis | A tight stricture was observed at the pancreatic neck, with a small amount of contrast in the dilated duct upstream of the stricture. The minor papilla was sought but could not be convincingly located, and cannulation was unsuccessful despite multiple attempts. | Conservative treatment with intravenous antibiotics and drip. |
ERCP: endoscopic retrograde cholangiopancreatography, MRCP: magnetic resonance cholangiopancreatography, CBD: common bile duct, CHD: common hepatic duct.
Following ERCP, 8 patients underwent definitive surgery: 3 choledochal cyst excision, 1 Puestow’s surgery, and 5 laparoscopic cholecystectomy for gallstones. Two patients were recommended surgery, but defaulted. One of them was diagnosed with a choledochal cyst, which was recommended for excision, and the other had recurrent pancreatitis with pancreatic duct stricture, which would have benefited from distal pancreatectomy.
DISCUSSION
In this retrospective audit, pediatric ERCP achieved a high success rate, with a desired duct cannulation rate and technical success rate of 94.7%. This success rate is comparable to other large-cohort pediatric ERCP, with reported rates of 92.2–95.2% [4,6,14,15]. The high success rate was achieved despite most procedures involving complicated endoscopic interventions, with over half of the cases classified as ASGE level ≥3.
ERCP was also technically feasible and successful in younger patients, with the youngest being 19 months old and weighing 8 kg. Four of the 38 (10.5%) ERCPs performed were in patients <6 years old at time of ERCP. This contrasts with a large study published in 2013 by Enestvedt et al. [4], where only 5% of their patients were <6 years old. ERCP can be challenging in children, as they have physiologically larger tonsils and smaller airways that may be at risk of airway compression with inappropriately sized scopes. Children also have smaller luminal diameter, papillae, and duct diameter, which makes duct cannulation more difficult [1]. Nonetheless, ERCP was increasingly performed for young children and even infants over the years with advancements in the design of pediatric duodenoscopes [15]. The use of standard adult duodenoscopes for ERCP in children aged >12 months and weighing >10 kg has also been proven to be feasible and efficacious [1,16]. All ERCP procedures in our study were performed using standard adult endoscopes and accessories. In a 2022 study in Sri Lanka, 62 pediatric patients underwent 98 ERCP procedures. All were successfully and safely performed by gastroenterologists routinely treating adults, using adult endoscopes and accessories [17]. Table 4 summarizes the comparison between adult and pediatric ERCP procedures.
Table 4. Key differences between adult and pediatric ERCP.
| Factors | Adult ERCP | Pediatric ERCP | |
|---|---|---|---|
| Indications | • Gallstones | • Gallstones | |
| • Acute and chronic pancreatitis | • Acute and chronic pancreatitis | ||
| • Biliary and pancreatic cancers | • Congenital anomalies such as biliary atresia, choledochal cysts and pancreatic duct abnormalities | ||
| Technical considerations | Standard adult endoscopes can be used. | Standard adult endoscopes can be used but pediatric scopes need to be considered in smaller children less than 10 kg. | |
| Special considerations: | |||
| - Children have physiologically larger tonsils and smaller airways so duodenoscopes need to be appropriately sized. | |||
| - Children may also require thinner and smaller accessories such as cannulas and guidewires due to smaller size of the bile duct and pancreatic ducts. | |||
| Therapeutic interventions | A broad range of interventions such as sphincterotomy, stone extraction and stent placement can be performed | ||
| Expertise and setting | Adult gastroenterologists certified in performing ERCP, usually under conscious sedation | May be performed by adult gastroenterologists with specialized training in pediatric ERCP. Often multi-disciplinary and usually in collaboration with pediatric gastroenterologists and anaesthesiologists to support the procedure. | |
| Risks and outcomes | High success rates (75–95%) | High success rates (~95%) | |
| Post-ERCP pancreatitis is the most commonly reported complication. | Post-ERCP pancreatitis is the most commonly reported complication. | ||
ERCP: endoscopic retrograde cholangiopancreatography.
With the greater availability of noninvasive diagnostic investigations, such as magnetic resonance pancreatography, almost all ERCPs are now performed for therapeutic indications [18]. Indications for pediatric ERCP vary depending on age group, ranging from patients with biliary atresia, choledochal cysts, and other pancreaticobiliary malformations to more common conditions such as choledocholithiasis [15]. Majority of ERCPs performed are for gallstone disease in both pediatric and adults, and it accounts for nearly 50% of ERCPs performed in our cohort. This patient profile is similar to that of other studies reporting a predominance of biliary indications [8]. This may also be attributed to the relatively higher local rates of children with chronic hemolytic disorders such as transfusion-dependent thalassemia with a predisposition for stone formation.
Our patients benefited from various therapeutic ERCP interventions with an acceptably low rate of ERCP-related complications (10.5%). Our complication rate is comparable to that of larger pediatric ERCP series, which report overall complication rates of 7–10.8% [8,14]. Post-ERCP pancreatitis is the most frequently reported complication, with one large single-institution study reported an incidence of 12.8% [19]. Risk factors for post-ERCP pancreatitis in pediatric cohorts are pancreatic conditions and higher ASGE complexity scores, which grade the difficulty of the ERCP procedures performed [20]. Both patients with post-ERCP pancreatitis in our study underwent complex ERCP interventions, including biliary sphincterotomy, pancreatic duct cannulation with contrast, and basket trawling for stones. The ASGE and European Society for Pediatric Gastroenterology, Hepatology, and Nutrition have recommended the prophylactic use of rectal non-steroidal anti-inflammatory drugs (NSAIDs) to reduce the incidence and severity of post-ERCP pancreatitis in high-risk individuals [21,22] and these guidelines were practiced in our institution. Before 2020, rectal NSAIDs were not routinely administered for post-ERCP pancreatitis prophylaxis as the institutional protocol had not been established.
Three out of 4 of our patients who had complications had challenging anatomy (2 had choledochal cysts and 1 had pancreatic duct stricture in which ERCP failed twice). We postulate that the challenging anatomy is technically more difficult to navigate, thereby predisposing patients to a higher risk of complications. Recent studies have also found that increased case complexity and interventions affecting the pancreatic duct, particularly in patients with pancreatic divisum and pancreatic stricture/stenosis, are associated with increased adverse events [6].
Singapore is a city-state in Southeast Asia with a relatively small pediatric population of under 800,000 out of an overall population of 6 million [23]. The number of pediatric cases requiring ERCP is expected to be low and infrequent compared with pediatric cases from larger populations. Despite the low caseload of 1–7 procedures per year (Fig. 1), pediatric ERCP can be safely and effectively performed by skilled endoscopists who routinely manage adults, using standard adult duodenoscopes. This has been common practice in many pediatric centers, which refer their ERCP cases to adult units because the low caseload has resulted in paucity of trained pediatric endoscopists [7]. Our center has shown good outcomes through coordinated care between pediatric and adult gastroenterologists as well as pediatric anesthetists to facilitate optimal preprocedure preparation, sedation and anesthetic care, and post-ERCP monitoring. Endoscopists primarily trained in adult practice also face challenges related to pediatric anatomy with a wide range of patient ages, sizes and physiology. Therefore, we recommend maintaining pediatric ERCP competency within a select core team of ERCP endoscopists in low-volume setting. Preprocedural imaging, such as magnetic resonance cholangiopancreatography (MRCP), can help delineate anatomy and anticipate technical challenges. However, in very young patients MRCP requires sedation or GA, adding an additional anesthetic event. The use of pre-procedure imaging should therefore be individualized based on the clinical indications and the physician’s discretion and experience.
Study limitations
The inherent biases related to the retrospective, single-center methodology of the audit as well as the small sample size may affect the generalizability of our results to other pediatric populations. Nonetheless, this audit aimed to present an overview of our local pediatric ERCP experience and show that it is safe and efficacious for the treatment of pancreaticobiliary diseases in children.
Conclusion
Pediatric ERCP proved highly successful and safe, even in a low-volume setting, with complex ERCP interventions performed in a diverse range of patient demographics and pancreaticobiliary diseases. Pediatric patients undergoing ERCP require coordinated care from both pediatric and adult gastroenterologists to achieve optimal and safe outcomes.
Footnotes
Funding: None.
Conflict of Interest: The authors have no financial conflicts of interest.
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